|
■ �' ection Re mber
<br /> Waste Tire fury & Inspection Reportns ort Nu
<br /> p p
<br /> StateBCalifornia Survey Form - Page 1 lZ -
<br /> CIWMB 181(New 04/04)
<br /> 1006 3
<br /> California Integrated Waste Management Board -
<br /> Part A Survey BLUE OR BLACK INK PEN
<br /> .myf 1z „ •
<br /> �r �,ttrrir/ t � � lfe �ra
<br /> f..E+MiS) ...mr's_'S t: ?'f,N
<br /> 77 �n
<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffix: J_ 1 Q Routine Q Re-inspection Referral Q Observation
<br /> Local � If Referral,choose referral type(Fill one)
<br /> Identifier: �•,, , =. f:I r Q CHP Q CIWMB Q Complaint 0 Educational Visit Q Other
<br /> Business or Facility Name �.
<br /> Inspected By Inspector
<br /> Physical Address r� 7 — / /76/
<br /> !" ,r
<br /> Street
<br /> L Inspection Date f
<br /> City State ZIP Code Time In Time Out
<br /> Business Rep Title t AM OAM
<br /> T
<br /> C / 1 Q PM O PM
<br /> 15
<br /> Business
<br /> Operational Status rrr' r Business Role
<br /> (Fill one only) tl�w } (Fill all that apply)
<br /> Q Active �" b"rr �"a Q Generator
<br /> O "
<br /> ® Closed1"�f�
<br /> Latitude - M " wr X�« tl ��rr
<br /> GPSr Q Hauler
<br /> � Q Inactive
<br /> Longitude — Q �'" Q End-Use
<br /> Lon
<br /> 9 Planned . �,„� "a"m
<br /> ,,..,: M Mr,,»: u, w M f f; r ,. a ,, C r”M rr I"r ,r6 ,F ,r M+4p,ru ' I r * u r r �".., S rsN,. ,N rr� X ^rC5 +✓' r 7
<br /> p '�` i.t., _,.,',y;y,.,u' ,..,.._....".�C�.6,`. z., u..wr!.�.- ". a..�.,. M,.. , ✓s....'�.�e's"cd1,?"����.4/Y3"�:x"3..s ..a-+ ��,. ..trr #u ,tlr,�,6rr. �y!"� sd' eM..,,+ >r�n k.L,.�L ,",N.< .:I,t...�_., �
<br /> Q New Tire Dealer Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel
<br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber
<br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V A HAULING AND MANIFEST REQUIREMENTS
<br /> I Q Notice Of Violation Q Extension
<br /> Q
<br /> Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> Q Q PRC§42956-Registration/Decal in Vehicle
<br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m
<br /> Q I Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)
<br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years
<br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement
<br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _
<br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations
<br /> Q Q Other: §
<br /> Comments
<br /> i ..
<br /> y
<br /> Inspection Form Included QI "a r W „ �CCPC ro" wvp r. WrXx4 aM!a" � hr i w 4` art a °f X yr d a .
<br /> nay. �''IM' � , .1+X, r �^f! a ✓}��:
<br /> Comments Included: Q
<br /> Business Rep's Signature Phone Number Inspector '"
<br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X i X.,
<br /> ,. r/. +raw 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
<br />
|